AP Tandon

Bjoern Kitzing

KA Eagle

MS Shin

T Yamada

Yu Xuan Li

English

PubMed

Yu Li

Springer - Publisher Connector

Fish bone ingestion mimicking aortic dissection: a case report

BioMed CentralCases Journal
ssOpen AcceCase Report
Fish bone ingestion mimicking aortic dissection: a case report
Bjoern Kitzing*1 and Yu Xuan Li2
Address: 1Westmead Hospital, Cnr Hawkesbury and Darcy Roads, Sydney, New South Wales, Australia and 2Royal Prince Alfred Hospital, 
Department of Radiology, Missenden Road, Sydney, New South Wales, Australia
Email: Bjoern Kitzing* - bkitzing@gmail.com; Yu Xuan Li - yuxuansophie@yahoo.com.au
* Corresponding author    
Abstract
Introduction: The lodgement of fish bones during ingestion is a common complaint and can mimic
other medical conditions such as aortic dissection.
Case presentation: In this case a non-English speaking 63-year-old Chinese man presented to the
emergency department with chest pain and hypotension. Subsequent spiral computed tomography
angiography ruled out aortic dissection but demonstrated a lodged fish bone tenting the
oesophagus in the non-contrast phase.
Conclusion: This case highlights the importance of this imaging modality as well as the role of a
good history in establishing an early diagnosis.
Introduction
We present a case of fish bone ingestion mimicking aortic
dissection and demonstrate the importance of good his-
tory taking as well as the significance of the non-contrast
phase of spiral CT angiography.
Case presentation
A non-English speaking 63-year-old Chinese man with a
medical history significant for smoking presented to the
emergency department complaining of chest pain. Symp-
toms had begun 2 hours prior to hospital admission, and
consisted of a sharp, stabbing, substernal pain, starting
shortly after a meal, and progressing gradually since then.
The pain radiated to the patient's back, jaw and left arm.
It was also pleuritic in nature as well as worse on swallow-
ing and talking. The medical history was otherwise unre-
markable.
On physical examination the patient appeared restless.
His blood pressure was 116/86 on the right side and 96/
56 on the left, pulse was 60 beats/min and regular, respi-
ratory rate was 16 breaths/min and oral temperature was
36.8°C. His examination also revealed normal jugular
venous pressure and normal breath sounds over both
lung bases. The chest pain could not be reproduced on
palpation. Heart sounds were distant, and peripheral
pulses were normal. The remainder of the examination
findings were unremarkable.
The ECG performed on hospital admission showed nor-
mal sinus rhythm with concave ST-elevation in V2 and V3.
The initial creatinine phosphokinase concentration was
329 ng/mL (normal reference range, 30 to 220 ng/mL),
the MB isoform fraction was under 3%, and troponin T
concentration was under 10 ng/mL which is also within
the normal reference range. The WBC count was 7700
cells/μL with 50% neutrophils.
The chest radiograph obtained showed no abnormalities.
4 hours after admission the patient became hypotensive
Published: 10 October 2008
Cases Journal 2008, 1:233 doi:10.1186/1757-1626-1-233
Received: 22 July 2008
Accepted: 10 October 2008
This article is available from: http://www.casesjournal.com/content/1/1/233
© 2008 Kitzing and Li; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2008, 1:233 http://www.casesjournal.com/content/1/1/233(systolic blood pressure was 80) and bradycardic (50
beats/min). Due to concerns for an underlying aortic dis-
section, a CT spiral angiography (Fig. 1 and 2) was
ordered.
The CT spiral angiography ruled out aortic dissection.
However, multiple linear calcific densities were seen in
the oesophagus and in the small bowel on the non-con-
trast phase of the study. One of the linear calcific densities
was in a transverse orientation and seen tenting the
oesophagus. The patient gave a history of ingesting fish
half an hour prior to the onset of pain. The diagnosis of
fish bone ingestion mimicking aortic dissection was
made. Rigid endoscopy was performed and a fish bone
was removed from the oesophagus approximately 20 cm
from the incisor. No bleeding or ulceration was seen.
Postoperative vitals were of a pulse of 72 beats/min and
blood pressure of 125/70. Transthoracic echocardiogram
showed that left and right ventricular function was nor-
mal, and that there was no apparent valvular disease.
Serial troponin tests were negative. The patient had an
uneventful recovery with intravenous antibiotic cover and
was discharged home on Day 3 following admission.
Conclusion
The lodgement of fish bones during ingestion is a frequent
complaint. Its main complications are airway obstruction
and oesophageal trauma. Rarer complications reported in
the literature include the development of aortoesophageal
fistula [1], or migration along an atypical tract. A careful
history is important in establishing an early diagnosis. In
this particular case, the patient was non-English speaking
leading to difficulty in obtaining a satisfactory history.
The patient's presentation of chest pain and hypotension
mimicked that of aortic dissection. Hypotension is often
clinically associated with haemodynamic compromise
and suggests major injury. However, the hypotension in
this case was due to vagal plexus stimulation by the trans-
versely orientated fish bone. The patient had bradycardia
rather than tachycardia which supported the diagnosis of
a vagal overtone rather than haemodynamic compromise.
The clinical appearance of aortic dissection is diverse.
Patients with aortic dissection may have signs and symp-
toms that mimic myocardial infarction, aortic regurgita-
tion, hypertensive crisis, pericarditis, cholecystitis,
cerebrovascular accident, spinal cord ischaemia,
mesenteric infarction, superior vena cava syndrome, acute
pulmonary disorders, or mediastinal neoplasms [2]. Con-
Select axial image of non-contrast phase CT showing a fish bone measuring 3 cm in the oesophagusFigure 1
Select axial image of non-contrast phase CT showing 
a fish bone measuring 3 cm in the oesophagus.
Select coronal image of non-contrast phase CT showing the fish bone lying transversely tenting the oesophagusFigure 2
Select coronal image of non-contrast phase CT 
showing the fish bone lying transversely tenting the 
oesophagus.Page 2 of 3
(page number not for citation purposes)
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versely, other diseases may look like aortic dissection
[3,4].
Previously, the gold standard diagnosis of aortic dissec-
tion was formal angiography. Following the introduction
of multi-detector computer tomography, the imaging
modality of choice is spiral CT angiography. Whilst the
contrast phase of the study which outlines the lumen is
sensitive for dissection flap, the non-contrast phase of the
study is sensitive for acute haematoma, intramural hae-
matoma and aortic calcification. It is also useful in depict-
ing other pathological entities with similar manifestations
such as a lodged fish bone as in this case.
To conclude, this is a case of vagal hypotension due to
lodged fish bone mimicking aortic dissection. The clinical
pathway demonstrated the importance of good history
taking and also the significance of the non-contrast phase
of spiral CT angiography.
Abbreviations
CT: computed tomography; ECG: electrocardiogram;
WBC: white blood cell.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
BK made substantial contributions to conception and
design and drafted the manuscript. YXL revised it critically
for important intellectual content and gave final approval
of the version to be published.
Consent
Written informed consent was obtained from the patient
for publication of this case report and all accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
References
1. Yamada T, Sato H, Seki M: Successful salvage of aortoesopha-
geal fistula caused by a fish bone.  Ann Thorac Surg 1996,
61:1843-1845.
2. Tandon AP, Lukacs LI, Cooke NJ, Ionescu MI: Dissection of the
aorta mimicking lung tumour.  J Cardiovasc Surg 1980,
21:251-252.
3. Shin MS, Ho KJ, Kirklin JW, Sears NJ: Metastatic mediastinal neo-
plasm masquerading as aortic dissection: a skip sign on com-
puted tomography for their distinction.  J Comput Assist Tomogr
1983, 9:299-303.
4. Eagle KA, Quertermous T, Kritzer GA: Spectrum of conditions
initially suggesting acute aortic dissection but with negative
aortograms.  Am J Cardiology 1986, 57:322-326.Page 3 of 3
(page number not for citation purposes)


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Fish bone ingestion mimicking aortic dissection: a case report

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